Form 16AWE Attachment E CureTB Contact_Source Investigation

OMB Approved

Control No 0920-XXXX

Exp Date: XX/XX/XXXX

TB Contact/Source Investigation (CI/SI) Notification

Telephone: (619) 542-4013 Fax: (404) 471-8905

¹Referring Jurisdiction: ¹Date sent:

City County State

¹Contact person: ¹Telephone. Ext. Fax:

Referring Agency: E-Mail Address:

Index Patient Information for: Contact Investigation Source Investigation

Index Patient Information

¹Name: Sex: M F

^{Paternal Maternal First Middle}

Alias: ______________________________________ DOB or Age: ___________ Parent’s Name (If child for SI): _________________________________

^{Number Street Apt City}

Home Phone: Cell:

^{County State Zip code}

Check if patient/parent not currently at home. Current location: Tel.:

Contact person: Name: Home Phone: Cell:

Relationship: E-Mail Address:

Clinical Information:

Treatment: ______________ Start Date: ___________

Site (s) of disease: Pulmonary Meningeal Disseminated Other(s), specify: _____________________________________________________

2Date of collection	2Specimen type	2Smear	Culture	Susceptibility
				Drug	Sens	Comments: Res
				INH
				RIF
				EMB
				PZA

HIV Diabetes No Symptoms Symptoms, specify:

Primary Address of Exposure

Contacts/Possible Sources

Address:

Country Telephone:

Name	DOB or Age	Relationship to Index Patient	Date Last Exposure	Phone # (H=Home; C=Cell)	Risk Factors			Sx	On Tx
					5 y/o	HIV/ AIDS	Immunosuppression

Other Address of Exposure

Address:

Country Telephone:

Name	DOB or Age	Relationship to Index Patient	Date Last Exposure	Phone # (H=Home; C=Cell)	Risk Factors			Sx	On Tx
					5 y/o	HIV/ AIDS	Immunosuppression

Comments:

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

1. Fields required to initiate the referral process

2. Please send imaging and laboratory reports as attachments.

3. Please attach additional information, as needed.

Centers for Disease Control and Prevention

Division of Global Migration and Quarantine

E-Mail: [email protected]